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In August 2013 the President’s Sandy Rebuilding Task Force presented a
comprehensive strategy for rebuilding after the October 29, 2013 storm.1 The
strategy outlined a set of recommendations intended to guide federal disaster recovery
decisions specific to Hurricane Sandy and inform planning and decision-making
related to future natural disasters and changing climate conditions. Among some of
the principles that guided Task Force recommendations were the following:
• Beforwardlooking – Decisions made after natural disasters and as part of
resilience planning will have impacts for decades to come. Therefore decision-
makers are urged to anticipate future environmental conditions and risks
and to assess impacts of decisions on multiple systems, including those that
affect public health and safety, community development and social cohesion,
ecological restoration, critical infrastructure, and regional economies.
• Basedecisionsonscience – The timely and systematic integration of scientific
evidence and science-based analysis will inform sound, cost-effective decision-making that employs quantitative
and qualitative data.
• Identifythemostvulnerable – Because certain segments of the population are especially vulnerable to impacts
of natural disasters and changing climate conditions, high priority should be accorded to involving them on
decisions about risk and resilience.
• Undertaketransparentandinclusivedecision-making – The visioning and planning needed to ensure
creation of communities that are inherently and sustainably resilient necessitates engagement with a diverse set
of stakeholders for the purposes of fostering the integration of local knowledge into planning and to ensure that
outcomes reflect shared community goals.
1 “Hurricane Sandy Rebuilding Strategy: Stronger Communities, A Resilient Region.” Hurricane Sandy Rebuilding Task Force. August 2013. http://portal.hud.gov/hudportal/documents/huddoc?id=hsrebuildingstrategy.pdf.
July 2016
Advancing Integration of Health and Community Engagement in Pre-Disaster Recovery and Resilience Planning:
Opportunities for Health Impact Assessment
Experiences and Insights from a Comprehensive Health Impact Assessment Initiative led by Rutgers University with support from the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and The Pew Charitable Trusts. The views expressed are those of the authors and do not necessarily reflect the views of the Health Impact Project, the Robert Wood Johnson Foundation or The Pew Charitable Trusts.
2
With support from the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew
Charitable Trust, Rutgers University explored how the practice of Health Impact Assessment (HIA) can be applied in the
context post-disaster recovery and resilience planning. The project examined how HIA might serve as a tool to address the
themes outlined in the Hurricane Sandy Rebuilding Task Force Report as well as to more systematically integrate health
consideration into pre-disaster resilience planning.
Toward this end, Rutgers conducted two HIAs designed to inform on-going disaster recovery and resilience planning decisions
in two case study communities. Both HIAs:
• Fostered forward-looking consideration of the short- and long-term health outcomes that may result from
implementation of specific resilience approaches;
• Integrated quantitative and qualitative data and evidence to inform decision-makers on the potential
consequences of proposed strategies; and
• Engaged community stakeholders and members of the public, including particularly vulnerable populations in,
open public processes that were both transparent and inclusive.
The case study HIAs illustrate how the structure, yet nimble process of health impact assessment can improve public
planning and decision-making both before and after a disaster.
About Health Impact Assessment
Health Impact Assessment (HIA) is a fast-growing practice in the U.S. that provides practitioners and policymakers with a tool
to measure the health outcomes of decisions. The National Research Council of the National Academies defines HIA as “…a
systematic process that uses an array of data sources and analytic methods and considers input from stakeholders to determine
the potential effects of a proposed policy, plan, program, or project on the health of a population and the distribution of those
effects within the population. HIA provides recommendations on monitoring and managing those effects.”2
According to the Health Impact Project, HIAs:
• Use a broad perspective that considers social, economic and environmental influences on health;
• Bring community members, businesses and other stakeholders together to help build consensus;
• Acknowledge trade-offs among choices under consideration;
• Analyze health concerns in the context of other important factors when making a decision;
• Consider whether certain impacts may affect vulnerable groups in different ways;
• Offer comprehensive information and practical recommendations to maximize health gains; and
• Minimize adverse effects.
HIAs typically include six steps: Screening, Scoping, Assessment, Recommendations, Reporting, and Evaluation.3 The
Rutgers-led HIAs followed generally accepted Minimum Elements and Practice Standards for Health Impact Assessment.4
2 Improving Health in the United States: The Role of Health Impact Assessment. Committee on Health Impact Assessment Board on Environmental Studies and Toxicology Division on Earth and Life Studies National Research Council. The National Academies Press, Washington D.C. 2011. http://www.nap.edu/catalog/13229/improving-health-in-the-united-states-the-role-of-health
3 See: http://www.pewtrusts.org/en/projects/health-impact-project/health-impact-assessment 4 Bhatia R, Farhang L, Heller J, Lee M, Orenstein M, Richardson M and Wernham A. Minimum Elements and Practice Standards for Health Impact
Assessment, Version 3. September, 2014.
Integrating Health into Disaster and Resilience Planning | July 2016 3
New Jersey HIA Initiative
The Disaster Recovery HIA initiative undertaken in New Jersey after Hurricane Sandy included two place-based HIAs along
with an examination of the value of HIA more generally in the context of disaster recovery and resilience planning. The
comprehensive evaluation benefitted from following the two New Jersey HIAs as case studies along with an extensive review of
how the process of HIA has been applied in the past as part of disaster recovery efforts and engagement of national HIA and
disaster recovery “thought leaders.”
The two HIAs undertaken in New Jersey were led by Rutgers University’s Bloustein School of Planning and Public Policy
with stakeholder engagement support provided by the non-profit organization New Jersey Future, and in cooperation with the
two municipalities in which the HIAs were conducted. The Georgia Health Policy Center provided technical assistance to the
Rutgers team on HIA methodology.
4
Case StudiesMystic Island
Mystic Island is an unincorporated, mostly residential community
within Little Egg Harbor Township, Ocean County. Bordering
the marshes that line Great Bay and Barnegat Bay, and open to
the Atlantic Ocean to the east, Mystic Island was created in the
1960’s. Several existing islands were joined together to create
buildable space on land inter-fingered with lagoon channels that
permit many houses to have direct access to open water in their
backyards. Originally a vacation destination for New Yorkers,
Philadelphians and people from other parts of New Jersey,
by the end of the 20th century a majority of the population
was living in homes converted for year-round use. Mystic Island’s geographic and topographic characteristics make it highly
vulnerable to repetitive flooding. The entire community is located within the 100-year floodplain, and Mystic Island has the
highest concentration of repetitive loss properties in Little Egg Harbor Township. Continued and worsening weather-related
impacts are predicted for this area because of projected sea level rise [SLR] and other problems associated with climate change.
Hurricane Sandy flooded much of Little Egg Harbor Township with almost seven feet of water, damaging more than 4,000
homes containing approximately 10,000 residents. Stakeholders involved in this study reported that the severity of Sandy’s
winds and storm surge were greater than those experienced in all previously storms and these problems were compounded by a
mixture of floating debris and toxic substances carried by flood waters.
Buyout and clearance of homes to create open space, combined with relocation of their occupants, is one mitigation strategy
under consideration by many vulnerable coastal communities. This strategy can serve several purposes: first, by creating a
protective open space buffer; second by moving families out of harm’s way; and third, by capturing additional ecological,
economic, aesthetic and recreational benefits by recreating or rejuvenating the highly productive wetland ecosystem that was
originally present. If bulkheads or “soft” engineering measures are installed, as part of the management of the open space, they
would provide further protection by breaking up waves and absorbing or dissipating their energy.
Lower income, elderly, disabled and youthful populations are
potentially vulnerable populations in Mystic Island that may
suffer negative outcomes in the event of a flood or receive
limited access to the benefits of flood protection. The Mystic
Island HIA identifies these subpopulations, and the assessment
focuses on impacts they may experience. Additionally, a buyout
initiative raises important equity considerations. Many of the
homeowners on Mystic Island have incomes lower than other
parts of the Township. As a consequence they may have fewer
options or resources to offset the negative impacts of potential
flooding, and are likely to have poorer health and access to health care. A decision about buyouts will impact these populations
to a greater degree than more affluent residents that possess superior mobility and greater resources.
The focus of the Mystic Island HIA was to assess the physical and mental health outcomes associated with the implementation
of voluntary buyout scenarios. Two hypothetical “buy out” scenarios were examined. The first scenario involved a buyout
Photo by Karen Lowrie
Photo courtesy Ira Wagner
Integrating Health into Disaster and Resilience Planning | July 2016 5
of approximately 100 contiguous parcels. This was considered the minimum number of properties that, when purchased and
cleared, could result in enough open space to increase resiliency. The second scenario is a buyout of 500 parcels. This is likely
the maximum number of properties that could be purchased with remaining available buyout resources. Both of the scenarios
propose purchasing a cluster of homes because this would achieve maximum environmental benefits. In the course of the HIA,
the “decision not to decide” about opting into the buyout program, the “no-action” alternative, has also been evaluated.
To completely and accurately assess the health impacts of the buyout scenarios, the team developed a proposed plan for
how the land will be used (for what purposes, who will benefit and in what ways) and how it will be maintained (costs and
responsibilities for upkeep, implications for community fiscal and public health). Feedback from the community indicated a
preference for assuring that the land is well-maintained and provides some community benefits. For the purposes of the HIA,
the research team envisioned the repurposed space as a wetland/marsh with multiple uses and benefits, developed with wetlands
and habitat preservation or endangered species funds from state or federal sources.
With input from the community Steering Committee, the Mystic Island HIA considered a diverse set of factors that influence
health related to property buy-outs as well as the positive and negative health outcomes that can result from those factors.
As outlined in Table 1, factors include the buyout’s impact on both severe and routine flooding, household financial health,
municipal fiscal health, open space and social cohesion.
The Mystic Island HIA affirmed that living in an area prone to regular small scale flooding and vulnerable to severe storm
flooding causes anxiety and other stresses related to lifestyle disruption and costs of damage repair; it can also exacerbate
respiratory conditions due to the growth and dispersion of mold. When severe storm events occur in these areas, health impacts
may be both severe and immediate (injury, exposure to debris and hazards) and for a long time after the disaster (stress and
related exacerbation of physical and behavioral conditions). Flooding can be more disrupting for the elderly or disabled who
have limited ability to find alternative routes, navigate flooded roadways, and may be more susceptible to health hazards.
The HIA provided substantial evidence of the mental health aspects of household financial difficulties associated with storm
recovery, but also of the potential for a buyout program to create new opportunities for improved mental and physical health
and strengthened social networks. Lower income individuals and households are most severely affected by the anxieties of living
with coastal flooding vulnerabilities and are most likely to benefit positively from efforts to improve resiliency.
TABLE 1: Factors Influencing Health Related to Property Buy-Outs in Mystic Island, New Jersey
6
The hypothetical voluntary buyout program presented in the HIA is one way
to build resilience and remove potentially thousands of people from harm’s way.
Recommendations from the Mystic Island HIA are aimed primarily at informing
decisions made by the local governing body, but they also provide insights
to inform planning by county, state and federal agencies involved in disaster
recovery. At the local level, recommendations and findings from this study will
inform the Little Egg Harbor Township council about whether or not to proceed
with support of a buyout program based on its impact on the health of the
community. But they will also help with understanding the health implications
of other resilience strategies and of the “do nothing” alternative. At the county,
state or federal agency level, the recommendations will help program officials
and decision-makers to adapt and implement disaster assistance and recovery
programs in ways that are built on an understanding of mental and physical health
impacts of disasters, and thus best promote and support the health of disaster
victims. Source: NJGIN MOD-IV 2014 Parcel Data
TABLE 2: Factors Influencing Health Outcomes Related to Adopting Amended Stormwater Management Plan and Hoboken Green Infrastructure Strategic Plan,
Hoboken, New Jersey
Integrating Health into Disaster and Resilience Planning | July 2016 7
Hoboken
Hoboken is a historic, densely populated city in urbanized Hudson County with more than 53,000
residents. The City was once an island surrounded by the Hudson River to the east and tidal marsh
on its western edge. Today, parts of western Hoboken still lie near or below sea level. Wastewater
treatment for Hoboken is provided by a regional authority that operates a Combined Sewer System
(CSS) that is designed to collect rainwater runoff, domestic sewage, and industrial wastewater in
the same pipes. During periods of heavy rainfall and high tides in the Hudson River, the volume of
water entering the combined sewer system exceeds the capacity of the treatment plant resulting in
back-ups that flood city streets and the basements of private property, while untreated wastewater
discharges directly into the Hudson River. Not only do these backups contain stormwater, they
may also contain untreated human waste, toxic materials, and debris from runoff. Although
flooding affects virtually every city resident in some way, a number of vulnerable groups may be
disproportionately impacted. These include minority and low-income populations, older adults,
persons with disabilities, populations with Limited English Proficiency, undocumented residents and
carless households.
The Hoboken HIA was designed to inform the City’s stormwater management planning
process and to examine the potential positive and negative health effects if the City decides to
adopt amendments to its Stormwater Management Plan and ordinances that would implement
recommendations of the Hoboken Green Infrastructure Strategic Plan. Implementation of “green infrastructure” is intended
to mitigate chronic flooding in the city and to help reduce the sanitary sewer back-ups and CSS events that often occur along
with the flooding. The HIA considered possible health effects of flooding and potential exposure to polluted stormwater
from combined sewer system back-ups and overflows; disruptions in local, emergency, and business services due to flooding;
and changes in water and air quality, as well as effects on ground
permeability and heating related to green infrastructure solutions.
The Hoboken HIA considered an extensive set of potential
health outcomes that could result from adoption of the amended
stormwater management plan and ordinances under consideration
by the City. As outlined in Table 2, changes in air and water quality,
access to open spaces, and exposures to hazardous substances, were
among the factors considered that can influence health outcomes.
The HIA confirmed that green infrastructure implementation in
Hoboken has the potential to provide many direct and indirect
benefits that can improve human health. At the same time there are
some potential risks. Some of these risks have already been identified
in publications and others were expressed by Hoboken residents
as legitimate concerns. A suite of recommendations were provided
as part of the HIA to enhance the positive and minimize the negative
health outcomes identified in the HIA.
Together North Jersey. (2013). Hoboken Green Infrastructure Strategic Plan.
8
FindingsIn general, the two HIAs led by Rutgers point to the promise of HIA to improve pre-disaster resilience planning in several
ways. The HIAs:
• Allowed stakeholders, leaders and decision-makers to consider health as a dedicated and explicitly desired
outcome, when it previously was not part of the decision process;
• Encouraged a structured and “democratic” process for engaging stakeholders (decision-makers, residents,
vulnerable populations alike) in sometimes difficult and contentious conversations about resilient community
planning;
• Highlighted the potential inequities of resilience planning outcomes, especially with regard to health impacts
(including mental health and social determinants of health);
• Provided a forum to introduce evidence-based, forward-looking information and analysis into community
dialogues about resilience planning.
Insights from this initiative point to the concept that HIA is a promising innovation with potentially large benefits, namely
benefits related to improving health for people in disaster impacted communities, and improving the process of pre-disaster
resilience planning to ensure engaged communities and sustainable solutions. Further, the results of the two HIAs suggests that
no fundamental changes are needed to make the HIA process useful in support of disaster recovery policies, plans and projects
but it would greatly benefit from a combination of modifications to make it more appropriately fitted for that purpose.
Several specific recommendations are offered to improve the efficacy of HIA to inform pre-disaster resilience planning:
1. InvestmajorefforttopublicizeHIAsamongtargetusergroupsincommunitiesofhazardandhealthprofessionals
thathaveresponsibilities,skillsand/orinterestsindisasterrecovery. Lack of awareness of the HIA process and
weak communications between health improvement and hazard management specialists are notable at present. There is
evidence of commitment to closer engagement of health and hazards agencies at the federal level but practical steps to
bring these communities – and especially their state and local counterparts - into fruitful interaction, are needed.
2. InsertHIAsintothedisasterrecoverydecision-makingsystematkeypointsofapplication. Mainstreaming HIAs
throughout the National Disaster Recovery Process is highly desirable and certain federal initiatives are disproportionately
important in achieving successful recovery from disasters, especially through funding and regulatory mechanisms. Given
the number and variety of post-disaster recovery decisions taken by impacted communities, guidance about the optimal
use of HIAs is not a simple matter. Recovery decisions that are broad in scope and early in the process are likely to have
the greatest long-term impact on human health and wellbeing. HIA offers value in assessing health outcomes of strategic,
or policy-related, outcomes (such as changes to the National Flood Insurance Program) as well as local blueprint-like
proposals like local zoning and rebuilding decisions. Federal Task Forces might be valuable conduits for recommending
wider use of HIAs by those who are engaged in making more detailed rebuilding decisions later in the recovery process.
So might local and regional climate adaptation plans, Hazard Mitigation Planning, or packages of proposals submitted by
states to the CDBG process.
3. Conductasystematicanalysisofthehealthimpactsofthefullrangeofdisasterrecoveryalternatives,withaview
toprovidingadatabankofinformationabouttheircomparativehealthoutcomesaswellasotherconsequences.
The value of any impact assessment, whether a NEPA-mandated Environmental Impact Statement or a Health Impact
Assessment or other, depends in part on the treatment of alternatives to the action that is the subject of assessment.
Without a comparative analysis of alternatives it is difficult to confirm whether the contemplated course is the best possible
Integrating Health into Disaster and Resilience Planning | July 2016 9
or how far it falls short of that standard. Ideally, a Health Impact Assessment of recovery alternatives would function as a
single reference source for use in subsequent disaster-recovery HIAs, thereby simplifying and speeding the screening stage
of full scale HIAs, which has proven to be the most problematic part of the process. Modified “desk top” HIAs could
be undertaken now on typical natural disaster related alternative decision-points in order to inform more comprehensive
stakeholder-driven, HIAs for specific strategic policy and/or local communities decision-making, as needed.
4. Providedecision-makersandHIAuserswithbetterguidanceforchoosingamongdifferentkindsofHIAsin
post-disastercontexts.Decisions about long-term recovery that are taken in the wake of disasters pose stiff challenges
for the HIA process. Post-disaster environments are usually marked by instability, uncertainty and urgency, factors that
are not conducive to lengthy in-depth inquiries at a time when clear thinking is called for. At present there is only limited
guidance about which of several different types of HIA (i.e. desktop, rapid, comprehensive, programmatic) might be best
able to provide useful information to decision-makers, either alone or in combination, under different local circumstances.
Community engagement that provides information inputs from disaster-affected populations is at the core of the HIA
process. Therefore it is imperative that such be facilitated to the greatest extent possible, though managing community
participation that is representative and informed is perhaps the most time-consuming and potentially fraught part of the
process.
5. ProvideappropriatetechnicalsupportforlocaladvocacygroupsthatseektouseHIAsforthejointreductionof
healthinequitiesanddisastervulnerabilities. Perhaps one of HIAs central values is that it uncovers and articulates grass
roots perceptions and knowledge pertinent to proposed public choices. A challenge that arises in HIA is how to assure
the reliability of lay information inputs and how to reconcile data that is volunteered by laypersons with data that has been
collected and compiled by systematic scientific means. In non-disaster situations the accuracy and reliability of scientific
information is generally high relative to that of lay populations and there is less need to interrogate its validity. But the
same is not necessarily true in the wake for disasters, where there may be gaps in existing information banks and insufficient
time to gather the data necessary to plug them, especially at the scale where local decisions about recovery are made.
There is significant potential for cross-learning between HIAs and other technical innovations that also rely on joint efforts
by experts and laypersons (e.g charrettes and visioning exercises; participant mapping using GPS and GIS technology;
volunteered geographic information that employs social media and cloud sources; and real time remotely sensed imagery of
ongoing events). It is recommended that research, education and training efforts be mounted to achieve those ends.
6. Encourageresearchorganizationstodevelopmethodsforintegratinghealthimpactassessmentswitheconomicand
environmentalimpactassessments. Almost a century of research on human responses to natural hazards and disasters has
shown that decision-making under conditions of environmental uncertainty is a complex task subject to multiple evaluative
criteria. The effect of disaster response measures on human health is one aspect of a larger set of decisions about health
assessment applications. Others include assessments of economic and environmental health. Already there are calls for
integrating several of these tools and such demands will likely grow. Because of its strong emphasis on public participation
in the shaping of decisions about health outcomes, Health Impact Assessment is a novel instrument that will pose
unusual challenges to the task of integration. It is not too soon to begin thinking about the role of HIAs in this process,
particularly how society should mediate and weight health considerations in the broader balance of social choices.
The three final reports for the Rutgers-led HIA Initiative can be found at: http://phci.rutgers.edu/post-disaster-recovery-resilience-planning/ along with materials from a public briefing on project outcomes. For more information, please contact
10
Planning Healthy Communities Initiative
Edward J. Bloustein School of Planning and Public Policy
33 Livingston Avenue
New Brunswick, N.J. 08901
[email protected] phci.rutgers.edu
© 2016, Rutgers, The State University of New Jersey